Risks Factors for Teenage Pregnancy and The Youth Perspective on Teenage Pregnancy and Health Needs in Nkalashane, Swaziland

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1 Risks Factors for Teenage Pregnancy and The Youth Perspective on Teenage Pregnancy and Health Needs in Nkalashane, Swaziland 7 th Africa Conference on Sexual Health and Rights 8-12 February 2016

2 Background Teenage pregnancy worldwide and in Swaziland 16 million women aged give birth each year (WHO), accounting for 11% of all birth worldwide Teenage pregnancies account for 23% of the overall burden of disease due to pregnancy and childbirth In Swaziland, more than one in five women reported to have had their first live birth before their eighteenth birthday Background 2

3 Background Teenage Pregnancy in Nkalashane Data from the Nkalashane Clinic shows that in 2014, 49% of pregnancies were teenage pregnancies. Teenage pregnancies at Nkalashane Clinic between 2011 and 2014, N (%) Total number of pregnancies (all ages) Pregnant women <19 years of age 2011 N (%) 2012 N (%) 2013 N (%) 2014 N (%) (16%) 12 (13%) 16 (18%) 21 (23%) Background 3

4 Background Teenage Pregnancy in Nkalashane Data from the Nkalashane Clinic shows that in 2014, 49% of pregnancies were teenage pregnancies. Teenage pregnancies at Nkalashane Clinic between 2011 and 2014, N (%) Total number of pregnancies (all ages) Pregnant women <19 years of age Pregnant women <23 years of age with 2 or more pregnancies 2011 N (%) 2012 N (%) 2013 N (%) 2014 N (%) (16%) 12 (13%) 16 (18%) 21 (23%) 17 (20%) 27 (20%) 21 (24%) 24 (26%) Background 4

5 Background Teenage Pregnancy in Nkalashane Data from the Nkalashane Clinic shows that in 2014, 49% of pregnancies were teenage pregnancies. Teenage pregnancies at Nkalashane Clinic between 2011 and 2014, N (%) Total number of pregnancies (all ages) Pregnant women <19 years of age Pregnant women <23 years of age with 2 or more pregnancies Total number of teenage pregnancies 2011 N (%) 2012 N (%) 2013 N (%) 2014 N (%) (16%) 12 (13%) 16 (18%) 21 (23%) 17 (20%) 27 (20%) 21 (24%) 24 (26%) 30 (36%) 39 (43%) 37 (42%) 45 (49%) Background 5

6 Objectives of the Study To determine the risk factors contributing to teenage pregnancy among the youth in Nkalashane. To gather information on how best to increase positive links between and among youth, teenage pregnancy prevention programs, and community-based clinical services. Background 6

7 Methodology The study was conducted in 3 parts: Part 1 Part 2 Part 3 A descriptive retrospective study to understand the risk factors of teenage pregnancy A descriptive crosssectional study to understand the services that are needed by the at-risk youth in Lomahasha to prevent teenage pregnancy. A descriptive crosssectional study to understand the challenges faced by the facility staff to prevent teenage pregnancy. Methodology 7

8 Methodology Part 1: A descriptive retrospective study to understand the risk factors of teenage pregnancy Inclusion criteria Teenage mothers: a woman who fell pregnant for the first time before 19 Teenage fathers: a man who impregnated a partner before the age of 19 Sampling method Data collection Teenage mothers: clinics registers and snowball sampling Teenage fathers: snowball sampling Data collection at Nkalashaneclinic or a place of convenience Conducted by 4 peer educators Teenage mothers: Questionnaires and focus group discussions Teenage fathers: Questionnaires Methodology 8

9 Methodology Part 2: A descriptive cross-sectional study to understand the services that are needed by the at-risk youth in Lomahasha to prevent teenage pregnancy. Inclusion criteria At-risk youth: between the ages of years that has never fallen pregnant/impregnated someone and enrolled in one of the three targeted schools Sampling method Data collection 26 participants (15 females and 11 males) were randomly selected from the three targeted schools: Nkalashane Primary, Nkalashane High and Mbokojweni Secondary school Data collection at each school Conducted by 4 peer educators Questionnaires and focus group discussions Methodology 9

10 Methodology Part 3: Descriptive cross-sectional study to understand the challenges faced by the facility staff to prevent teenage pregnancy. Inclusion criteria Nurses, orderlies, community workers and expert clients employed at Nkalashane Clinic at the time of the study Sampling method Data collection Each worker was asked by the study team whether they would like to be enrolled in the study Data collection at the Nkalashane clinic Questionnaires Methodology 10

11 RESULTS Part 1 : A descriptive retrospective study to understand the risk factors of teenage pregnancy Part 1 Teenage Mothers and Teenage Fathers 11

12 Socio-Demographic Characteristics of the Participants at the Time of First Pregnancy Highest Level of Education Completed by Mother/Female Guardian 60% 50% 40% 30% 20% 10% 0% 60% 50% 40% 30% 20% 10% 0% Teenage mothers (n=43) Teenage mothers (n=43) Teenage fathers (n=8) No schooling Primary school Secondary school Post Secondary school I don t know School level of teenage mother/father at time of pregnancy Teenage fathers (n=8) Primary school Secondary school Post Secondary school Out of school The majority of mothers/ female guardians had less than a primary school education 42% of teenage mothers had a family history of teenage pregnancy The majority of teenage mothers were in school at the time of pregnancy (64%), but only 19% went back to school after giving birth. Part 1 Teenage Mothers and Teenage Fathers 12

13 Influence of Intergenerational and Transactional Sex 60% 50% 40% 30% 20% 10% Teenage mothers partners were 5.2 years older (range:1-14 years) 93% of partners were from Swaziland Country of Origin of the Partner 7% Swaziland 93% South Africa 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Main source of financial support Myself My Family Baby's father Baby's father parents Another partner The majority of partners were educated (post secondary) Highest Level of Education Completed by Partner No schooling Primary school Secondary school Post Secondary school I don t know The majority of teenage mothers reported relying primarily upon their baby s father for financial support after giving birth Part 1 Teenage Mothers and Teenage Fathers 13 0%

14 Sexual History of Teenage Mothers and Teenage Fathers 70% 60% 50% 40% 30% 20% 10% 0% Reason for Sexual Debut I felt I was ready I was pressured Everyone else was doing it I was a victim of sexual violence Other Teenage mothers (n=43) Teenage fathers (n=8) Average age at first pregnancy was 17.6 for teenage mothers, and 18.5 for teenage fathers Average of sexual debut was 16.5 for mothers and 16.8 for fathers Only 30% of teenage mothers reported I felt I was ready as the reasons for sexual debut, compared to ~60% of teenage fathers. Part 1 Teenage Mothers and Teenage Fathers 14

15 Use of Contraception at Time of First Pregnancy Only 44% of Teenage mothers and 38% of Teenage fathers reported using contraception at the time of first pregnancy. What are the reasons for not using contraception? I didn t think I could get pregnant I didn t know about contraception My partner didn t want to use a condom Teenage Mothers No, 56% No, 63% Yes, 44% Teenage Fathers Yes, 38% 90% of teenage mothers and 100% of teenage fathers reported condoms as the method of contraception used What went wrong? Condom broke He/we wanted a baby We didn t always use contraception Part 1 Teenage Mothers and Teenage Fathers 15

16 Safe Sex Knowledge at the Time of First Pregnancy Self Reported Knowledge of Safe Sex Teenage Mothers 43% 7% 50% Very knowledgeable Somewhat knowledgeable Not at all knowledgeable Teenage Fathers 70% 60% 50% 40% 30% 20% 10% 0% Teenage mothers and fathers self reported as somewhat or not knowledge at all about safe sex Source of Information on Safe Sex Teenage mothers (n=43) Teenage fathers (n=8) A healthcare worker at the clinic/school health My teacher at school Internet/TV/radio My parents My friends Part 1 Teenage Mothers and Teenage Fathers 38% 63% The majority of Teenagers mother and fathers reported receiving information from HCW, as well as teachers, internet/tv/radio, parents and friends 16

17 Safe Sex Knowledge at the Time of First Pregnancy Participants were asked to report whether statements regarding safe sex were true or false, and were given a score out of 11 Teenage Mothers: 9.2/11 Teenage Fathers: 9.5/11 Examples of questions included: To be extra safe, it is good to 23% use two of the condoms teenage at mothers once said this was true A girl who is having 21% of sex the cannot teenage get mothers pregnant said if she this forgets was true to use the pill for a few days Birth control pills, injectables 16% of or the IUDs teenage can help mothers prevent said sexually this was transmitted true infections (STIs), including HIV/AIDS. Lack of knowledge on safe sex and contraception were discussed as risk factors for teenage pregnancy: So you find that the child grows up and get a boyfriend without having proper information and then they fall pregnant. Part 1 Teenage Mothers and Teenage Fathers 17

18 Support System, Healthy Behaviour and Relation at the Time of First Pregnancy Proportion of Teenage Mothers and Fathers who were Depressed at the Time of First Pregnancy Teenage Mothers 33% 77% Emotional state score >11 Emotional state score <=11 Teenage Fathers 72% 38% Part 1 Teenage Mothers and Teenage Fathers 18

19 Additional Risk factors of Teenage Pregnancy Lack of parental guidance I think as young people we lose our parents to death and we are left with grandparents who cannot advise us properly or will not have the energy to go after us in an attempt to stop us from doing things that would be harmful to us. Difficult access to contraceptives and perceptions of contraceptives Negative attitudes towards them from HCWs and shop keepers First of all the when the child visits the clinic, she will be asked so many judgmental questions about the kinds of services she is seeking considering her age. Misconceptions and negative feelings towards modern contraception It s not ok that a child should use contraceptives because they might cause the child not to be able to have her own kids when she is older as a result of using these from a very young age. Peer pressure Some fall pregnant as a result of peer pressure. You find that they talk among themselves that some of them are engaging in sexual activities and those that don t would feel like they are missing out on something exciting. When one decides to partake as well, she will unfortunately fall pregnant probably because her peers didn t tell her about using contraceptives. Part 1 Teenage Mothers and Teenage Fathers 19

20 RESULTS Part 2: A descriptive cross-sectional study to understand the services that are needed by the at-risk youth in Lomahasha to prevent teenage pregnancy. Part 2 At-Risk Youth 20

21 Demographic Information and Sexuality Knowledge Mean Age of Participants At-Risk Girls (N=41) 15.5 years At-Risk Boys (N=32) 16.1 years 13 years 18 years 12 years 19 years Self-Reported Sexuality Knowledge At-Risk Girls 15% 10% Very knowledgeable Somewhat knowledgeable At-Risk Boys 15% 18% Part 2 At-Risk Youth 76% Not at all knowledgeable 68% 21

22 Sexuality Knowledge Sources and Comfort 60% 50% 40% 30% 20% 10% 0% At-risk Youth's Current Source of Sexuality Information At-risk girls At-risk boys My teacher My parents A HWC/school health My friends Youth receive information about sexuality from a variety of sources, including parents and teachers Youth feel comfortable approaching HCWs and parents for sexuality information 50% 40% 30% 20% 10% 0% Who At-Risk Youth Feel Comfortable Approaching for Sexuality Information At-risk girls At-risk boys A HCW/school health My parents My teacher My friends Focus groups discussions highlighted lack of knowledge on contraceptives and relationships: The girls are not taught about sex back at home. Instead parents hide such facts from them and as a result the kids would want to experiment for themselves.

23 Sexuality Knowledge and Perceptions of Contraceptives Knowledge Score: At-risk girls: 8.5/11 At-risk boys: 8.3/11 41% of the at-risk girls and 38% of the at-risk boys thought Modern contraception can make you infertile 27% of the at-risk girls and 38% of the at-risk boys thought Birth control pills,, injectable or IUDs can help prevent sexually transmitted infections (STIs), including HIV/AIDS Primary school students were even more confused about the safe sex and contraception issues than thesecondary and high school students. 75% of the primary school students believed that drinking water after having unprotected sex prevents unwanted pregnancies. 54% thought that, to be extra safe, it is better to use two condoms at once. Part 2 At-Risk Youth 23

24 Sexual Behaviour and Contraception 12% of At-risk girls and 13% of At-risk boys were sexually active At-Risk Girls Use of Contraception At-Risk Boys Rarely, 20% Always, 80% Often, 50% Reasons for not using contraception I didn t think I/she could get pregnant Reasons for not using condoms It was spur of the moment/i didn t have any on hand I don t believe in them (personal/religious beliefs) Always, 25% Part 2 At-Risk Youth 24

25 Thoughts on Teenage Pregnancy Opinion on the Causes of Teenage Pregnancy At-Risk Girls At-Risk Boys 15% Mistake/Negligence 19% % 61% To keep their partner Other 54% 27% Ideal age for sexual debut reported by at risk youth (range: 18-30) Ideal age to have a child reported by at-risk youth (range: 18-36) Part 2 At-Risk Youth 25

26 At-Risk Youth who Discussed Contraception Methods with a Healthcare Worker At-Risk Girls At-Risk Boys Yes, 27% Yes, 18% No, 73% No, 82% I already know how to prevent pregnancy and STIs I don t feel comfortable in asking such questions The nurse does not have time I don t feel that my privacy and confidentiality are maintained Part 2 At-Risk Youth 26

27 Additional Perceived Risk Factors of Teenage Pregnancy Lack of parental interaction Some children don t have parents who will talk to them about sex and you find that they end up doing things without knowing how to do them appropriately. Peer pressure Young person would say that the one taking condoms is stupid by wanting to have sex while putting on a condom since there is nothing enjoyable in that. Intergenerational and transactional sex Some of our friends have a lot of material things which they get from having sex with some men. When we see this, we also want to have those things and then we would be required to do just as our friends When I am in a relationship with an old man, it will be difficult for me to say no to some things he wants us to do. Difficult access tocondoms and perceptions of contraceptives Some nurses shout at young people. When you go to take contraceptive, the nurses will judge you and ask why you want contraceptives at such young age. Part 2 At-Risk Youth 27

28 RESULTS Part 3: Descriptive cross-sectional study to understand the challenges faced by the facility staff to prevent teenage pregnancy. Part 3 Facility Staff 28

29 RESULTS Part 3: Facility staff Quantitative findings Type of Facility Staff Number of Participants Nurse 2 Expert Client 2 Orderly 2 Community Worker 1 Total 7 Reasons staff do not feel comfortable providing contraceptives to adolescents Because it is like giving a go ahead, it encourage sexual activities Religious belief Reasons staff feel comfortable providing Do contraceptives you feel comfortable to adolescents providing contraceptives Because they are to sexually adolescents? active Because they need to know how to protect themselves No, 29% Yes, 71% Although facility staff do not always feel comfortable providing contraception to adolescents, they reported that they would always provide it to any clients who asked for the following reasons: Because if I don't, she/he will have unprotected sex - he/she is sexually active I will also educate on the risks of early sexual debut To prevent unplanned pregnancy Part 3 Facility Staff 29

30 Discussion & Recommendations Increase collaboration between MOH, MOET and communities Comprehensive life skills/sexuality education Contraception education Increase psychosocial support Strengthen collaboration and linkage between schools and local clinics with greater communication and referral systems Strengthen school health programme Encourage young people to access health services Provide sexuality education not only to youth but also to parents and teachers Age-specific messaging for youth Continue development and roll-out of LSE curriculum for all school levels Educate youth on proper use of contraception, the importance of protecting against pregnancy and STIs Place condoms in easily accessible areas Clarify contraceptive misconceptions Encourage positive peer pressure among youth to delay sexual debut through community forums Utilize school guidance teachers to integrate peer education into school extracurricular activities to promote positive peer influences Discussion 30

31 Recommendations Advocate for youth-friendly services at facilities Youth-friendly services allow access to health services without judgment for personal choices or health care needs The MOH s youth-friendly services approach is capacitating nurses to offer youth-friendly services SRHU is targeting youth-friendly services training to at least 80% of nurses in each health facility Participants of this study acknowledged receiving safe sex information from nurses as well as other facility staff Suggestion to include all facility staff in youth-friendly services trainings Discussion 31

32 Acknowledgements Swaziland Ministry of Health The Study Team Busisiwe Prudence Tsabedze Zandile Masangane Amy Styles Nkalashane Clinic Lomahasha Inkhundla Clinton Health Access Initiative Swaziland Ministry of Education and Training Nonhlanhla Jabulile Sibisi Inessa Ba Lubumbo Regional Education Officers Nkalashane Primary School Nkalashane High School Mbokojweni Secondary School Superbuddies Last but not least, we offer our sincere appreciation to the facility staff, clients, and students at the selected sites that made this study possible. Discussion 32

33 Thank You! Discussion 33

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